Birth Centre drop-in registration form

First Name*

Last Name*

Thank you for joining me today at the Ottawa Birth and Wellness Centre.

I'd like to get to know you and your baby a bit better with the information collected from this form. Please answer the questions as best as you can remember.

Visit Information

Today's date *

Referred by (if applicable)

Parent information

Parent first name *

Parent last name *

Email address (for receipts, visit notes etc.) *

Phone number *

Baby's information

Baby's first name *

Baby's last name *

Baby's date of birth *

Baby's sex *

Gestational age at birth *

Birth weight *

Date of last weight check and how much the baby weighed *

Reason for visit

Please check all that apply

Any other concerns not captured in the list above?

Privacy statement

The information you share on this form and during your visit is collected to support your care and will be kept confidential. It will be stored securely and shared only, where relevant and with your consent, with other members of your healthcare team. Information will not be shared with any third party except where required by law (for example, a duty to report under child protection legislation). You may ask to see or correct your information at any time. Images and video may be very useful teaching tools for other parents, caregivers, students and healthcare professionals. Please select from the following list what you are comfortable with. You may change or withdraw your consent at any time. *

Contract of services

This Agreement outlines the terms and conditions between the Lactation Consultant ("Consultant") and the Client ("Client") for the provision of lactation consultation services. The role of the Consultant is to assist breastfeeding parents in achieving optimal breastfeeding outcomes by providing education, support, and guidance before, during, and after the breastfeeding process. The Consultant offers expertise in breastfeeding techniques such as positioning, latch, and infant feeding habits, and addresses challenges that may arise, including low milk supply, weight concerns, or other issues.

The Client is responsible for providing accurate and complete information regarding their medical history, breastfeeding goals, and any concerns related to breastfeeding or infant feeding. This includes any relevant health information about both the Client and the baby that may affect breastfeeding outcomes. The Client understands that the Lactation Consultant’s services do not replace medical care and agrees to consult their primary healthcare provider or pediatrician regarding any medical concerns about their health or their baby’s health. The Client agrees to inform the Consultant if there are any significant changes to their care plan made by their healthcare provider.

Fee

The fee for my services is pay-what-you-can, with a suggested donation of $20. Nobody will ever be denied care if they have financial need. If your financial situation requires today's session to be free, please comment the word "free" in the box below so that I can treat the check-out process with discretion.

I acknowledge that I have completed this form accurately to the best of my knowledge. I understand that the lactation support provided at this drop-in clinic is educational and supportive in nature, and does not replace ongoing medical care from my primary care provider or pediatrician. I consent to receive lactation support, including a visual and physical assessment of infant feeding, and understand I may decline any part of the assessment at any time. I understand that recommendations are offered based on the information available at the time of this visit.

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Your information is kept by the clinic for as long as its professional order requires, and your account data for as long as your account is active. A deleted record is permanently purged 45 days after its deletion. Details in our privacy policy.

Signature :

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